Superselective splenic artery embolization for the management of splenic laceration following colonoscopy

Splenic injury is a rare complication following colonoscopy with fewer than 100 reported cases worldwide to date. We describe a case of splenic laceration presenting 5 days following diagnostic colonoscopy. Although hemodynamically stable, active contrast extravasation on contrast-enhanced multidetector computed tomography predicted likely failure of conservative management. Splenic artery angiography confirmed active extravasation from the lower splenic pole and the patient was successfully treated with super selective coil embolization of a lower pole splenic artery branch. This is the eighth reported case of endovascular treatment of splenic injury following colonoscopy. To our knowledge, however, superselective splenic artery embolization has not been previously reported to treat this rare endoscopic complication

Interobserver agreement on non-contrast computed tomography interpretation for diagnosis of urolithiasis in patients with acute flank pain

OBJECTIVE: To evaluate the interobserver agreement on non-contrast computed tomography interpretation by a group of experienced abdominal radiologists, for the study of urolithiasis in patients presenting acute flank pain. MATERIALS AND METHODS: Prospective study of 52 patients submitted to non-contrast enhanced helical computed tomography. The images were subsequently analyzed by three independent observers, with the interobserver agreement assessed by means of the kappa (kappa) statistical method. The following parameters were analyzed: a) presence, localization and measurement of ureteral calculi; b) intrarenal calyceal system dilatation; c) perirenal fat heterogeneity; d) ureteral dilatation; e) ureteral wall edema (halo sign). RESULTS: Ureteral calculi were found in 40 of 52 patients (77%). The interobserver agreement was almost perfect as regards identification of ureteral calculi (kappa = 0.89) and ureteral dilatation (kappa = 0.87), substantial for calyceal system dilatation (kappa = 0.77), and moderate for perirenal fat heterogeneity (kappa = 0.55) and ureteral wall edema (kappa = 0.56). CONCLUSION: Non-contrast-enhanced abdominal computed tomography presents high reproducibility in the evaluation of urolithiasis and secondary signs of the calyceal system obstruction.OBJETIVO: Avaliar a reprodutibilidade da tomografia computadorizada sem contraste na avaliação da litíase ureteral e os sinais secundários de obstrução do sistema coletor em pacientes com cólica renal aguda. MATERIAIS E MÉTODOS: Estudo prospectivo de 52 pacientes com diagnóstico clínico de cólica renal aguda submetidos a exame de tomografia computadorizada de abdome sem contraste. Os exames foram realizados com técnica helicoidal e posteriormente analisados por três observadores independentes, com a concordância interobservador avaliada pelo método estatístico kappa (kapa). Foram analisados os parâmetros: a) presença, localização e mensuração dos cálculos ureterais; b) dilatação do sistema coletor intra-renal; c) heterogeneidade da gordura perirrenal; d) dilatação ureteral; e) edema da parede ureteral (sinal do halo). RESULTADOS: Foram encontrados 40 cálculos ureterais na tomografia computadorizada (77%). A concordância interobservador para a identificação do cálculo ureteral e da dilatação ureteral foi quase perfeita (kapa = 0,89 e kapa = 0,87, respectivamente), substancial para dilatação do sistema coletor intra-renal (kapa = 0,77) e moderada para heterogeneidade da gordura perirrenal e para edema da parede ureteral (kapa = 0,55 e kapa = 0,56, respectivamente). CONCLUSÃO: A tomografia computadorizada de abdome sem contraste apresenta elevada reprodutibilidade na avaliação da litíase ureteral e dos sinais secundários de obstrução do sistema coletor.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemColégio Brasileiro de Radiologia e Diagnóstico por ImagemUNIFESP, EPM, Depto. de Diagnóstico por ImagemSciEL

Lanreotide and octreotide complexed with technetium-99m: labeling, stability and biodistribution studies

Lanreotídeo e octreotídeo são octapeptídeos cíclicos análogos da somatostatina e têm sido marcados com Tecnécio-99m para uso em diagnóstico na Medicina Nuclear. Os peptídeos são preparados em solução tampão ftalato/tartarato contendo um agente redutor. O objetivo deste estudo foi a otimização da marcação direta variando alguns parâmetros e a avaliação da estabilidade radioquímica e biodistribuição em animais. Os peptídeos marcados foram obtidos com alta eficiência de marcação e sem a necessidade de etapa de purificação no final do processo. Os melhores resultados de radiomarcação corresponderam á razão molar de SnCl2.2H2O/peptídeo de 4,5. Os peptídeos-99mTc mostraram-se radioquimicamente estáveis por 6 horas. Octreotídeo-99mTc mostrou-se relativamente mais suscetível frente à cisteína do que o lanreotídeo-99mTc. Os peptídeos-99mTc foram principalmente distribuídos no trato gastrointestinal, porém o lanreotídeo-99mTc mostrou maior captação pelo fígado do que o octreotídeo-99mTc. Os resultados indicaram que os produtos podem ser obtidos com alto rendimento radioquímico e com procedimento simples, permitindo estudos posteriores para avaliação de sua eficácia em radiodiagnóstico.Lanreotide and Octreotide are cyclic octapeptide analogues of somatostatin that were labeled with the radioisotope Technetium-99m for use in diagnostic nuclear medicine. The peptides were processed in a tartrate/phthalate buffer solution containing reducing agent. The purpose of this investigation was to optimize direct labeling by varying some parameters, and to evaluate radiochemical stability and biodistribution in animals. The marked peptides were obtained with high labeling efficiency and no need for subsequent purification. Best radiolabeling results corresponded to a molar ratio of SnCl2.H2O/peptide of 4.5. 99mTc-peptides were radiochemically stable for 6 hours. 99mTc-octreotide was relatively more susceptible to cysteine challenge than 99mTc-lanreotide. 99mTc-peptides were mainly distributed in the gastrointestinal tract but 99mTc-lanreotide showed a greater uptake by the liver than 99mTc-octreotide. Results indicated that the products can be obtained with high radiochemical yield, in a simple routine appropriate for further studies to assess their efficacy in radiodiagnosis

Custo de medicamentos produzidos pelo Hospital Universitário, papel da Farmácia Central

The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clinicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.A Farmácia Hospitalar em instituições avançadas e de grande porte evoluiu de uma simples unidade de armazenamento e distribuição, para um centro de manipulação altamente especializado, responsável pelo processamento de centenas de requisições clínicas, muitas delas únicas e não disponíveis de fontes comerciais. Foi perfeitamente natural portanto que em muitos ambientes, um Serviço Industrial fosse gradualmente estabelecido, visando responder a demandas tanto convencionais como extraordinárias da equipe médica. Tal foi o caso do Hospital das Clínicas, onde múltiplas categorias de fármacos são rotineiramente elaboradas nas dependências da Farmácia. Entretanto, imperativos de contenção de gastos determinam que tais atividades sejam reajuizadas sob o prisma de sua eficiência e essencialidade. MÉTODOS: Num estudo prospectivo, a produção do Serviço Industrial da Farmácia Central durante um período de 12 meses foi documentada, e classificada em três modalidades. O Grupo I abrangia medicamentos similares a outros fornecidos comercialmente, no Grupo II foram listadas formulações de composição exclusiva, e finalmente o Grupo III espelhava pedidos especiais voltados para investigações clínicas. RESULTADOS: Os achados das diversas categorias assinalaram que 34,4%, 45,3% e 20,3% dos medicamentos elaborados correspondiam a estes três grupos, respectivamente.Os custos industriais foram calculados para os fármacos do Grupo I e comparados com valores de mercado, chegando-se a uma economia de 63,5%.Quando extrapolada para os outros dois grupos, relativamente aos quais não se contava com preços comerciais diretamente equivalentes, atingiu-se uma estimativa superior a 5 100 000 dólares de economia durante um ano de operação. Mesmo levando-se em conta que tais contas deixaram de lado muitos custos, notavelmente aqueles subordinados à comercialização e distribuição, foi lícito concluir que pelo menos parte da economia citada era verdadeira. CONCLUSÕES: A economia observada, em combinação com a eficiência e confiabilidade com que a Farmácia desempenhou suas obrigações, vieram ao encontro do ponto de vista de que a manufatura interna de drogas foi uma alternativa vantajosa sob o prisma de custos, no contexto descrito

Efeitos da administração contínua versus intermitente da nutrição enteral em pacientes críticos

PURPOSE: Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted. PATIENTS AND METHODS: Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients. RESULTS: Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet. CONCLUSIONS: Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.ANTECEDENTES: A alimentação enteral é a modalidade preferida de suporte em pacientes graves com função digestiva aceitável porém incapazes de se alimentar por via oral, entretanto as vantagens da oferta contínua em contraste com a intermitente são rodeadas de controvérsias. Tendo como objetivo identificar os benefícios e as complicações destas técnicas, realizou-se um estudo prospectivo e controlado com casos pareados. PACIENTES E MÉTODOS: Vinte e oito pacientes consecutivos candidatos a alimentação enteral foram divididos em dois Grupos (n= 14), pareados segundo diagnóstico e índice APACHE II.Uma dieta polimérica comercial imuno-estimulante foi administrada por sonda nasogástrica e bomba de infusão na proporção de 25 kcal/kg/dia, em forma de bolo por uma hora a cada três horas (Grupo I), ou continuamente nas 24 horas (Grupo II), durante três dias. Os métodos incluiram antropometria, dosagens bioquímicas, registro de uso de drogas e outras terapêuticas, RX de tórax, circunferência abdominal, resíduo gástrico, e avaliação clínica e nutricional, efetuada no mínimo uma vez por dia. Os principais desfechos colimados neste estudo foram frequência de distensão abdominal e aspiração pulmonar, e capacidade de atingir a meta calórica pretendida. RESULTADOS: Quase metade da população total (46,4%) apresentou resíduos gástricos elevados em pelo menos uma ocasião, porém somente foi registrado um episódio confirmado de aspiração pulmonar (3,6%). Ambos os grupos padeceram de um número moderado de complicações, sem diferenças. O ganho de dieta no Grupo II foi maior no primeiro dia, porém no terceiro dia ambos os grupos exibiam déficits pequenos e semelhantes no ganho dietético, quando comparados com o volume prescrito. CONCLUSÕES: Ambas as modalidades de oferta permitiram a administração prática e eficiente da dieta, com freqüentes anormalidades registradas porém escassas complicações clinicamente significativas. Os dois grupos se comportaram analogamente, com poucas diferenças nos resultados, provavelmente devido à técnica meticulosa, monitorização cuidadosa, rígido pareamento dos pacientes, e volumes modestos da dieta empregados nas duas circunstâncias. Investigações subseqüentes deveriam ser elaboradas com populações, grupos diagnósticos e prescrições dietéticas adicionais, a fim de elucidar as diferenças entre estas modalidades de alimentação comumente usadas

Non-surgical Interventions for Improving Nutrient Absorption in Pediatric Short Bowel Syndrome

Joel Faintuch,1 Andre Dong Won Lee,2 Salomao Faintuch,3 Asher Mishaly,4 Francisco Juarez Almeida Karkow5 1Department of Gastroenterology, Sao Paulo University Medical School, Sao Paulo, SP, Brazil; 2Liver and Digestive Organs Transplantation Service, Hospital Das Clinicas, Sao Paulo, Brazil; 3Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 4Private Practice, Internal Medicine, Sao Paulo, Brazil; 5Department of Clinical Nutrition, Fatima Faculty of Nutrition, Caxias do Sul, RGS, BrazilCorrespondence: Joel Faintuch, Senior Professor of Gastroenterology, Hospital das Clínicas, Avenida Eneias C. Aguiar 255, 9th Floor, Rm 9077, Sao Paulo, SP, 05403-000, Brazil, Email [email protected]: As recently as 1990, short bowel syndrome in infants with less than 6 cm of remaining small intestine beyond the ligament of Treitz was defined as irreversibly lethal, and withholding further treatment was considered reasonable at that time (Reference deleted, Reviewer 2 item 1). Intestinal transplantation was already available, however not highly reliable. Nowadays transplantation is associated with long-term survival, even though indications are not expanding. On the contrary, they are shrinking, particularly for children as non-transplant handling. Surgical lengthening of the remaining gut, and more recently by enterohormone supplementation to stimulate diarrhea reversal and gut rehabilitation, is permitting encouraging rates of long-term survival. The purpose of this study was to review current non-surgical interventions aiming at parenteral nutrition weaning and intestinal failure reversal in the short bowel syndrome population, with emphasis on pediatric cases.Keywords: intestinal failure, gut rehabilitation, enterohormones, GLP-2, GLP-1, food supplements, short bowel syndrom

Association Between Nutritional Status and the Immune response in HIV + Patients under HAART: Protocol for a Systematic Review.

Over 850 million people worldwide and 200 million adults in Sub-Saharan Africa suffer from malnutrition. Countries most affected by HIV are also stricken by elevated rates of food insecurity and malnutrition. HIV infection and insufficient nutritional intake are part of a vicious cycle that contributes to immunodeficiency and negative health outcomes. However, the effect of the overlap between HIV infection and undernutrition on the immune response following antiretroviral initiation remains unclear. A possible explanation could be the lack of consensus concerning the definition and assessment of nutritional status. Our objectives are to investigate the existence of an association between undernutrition and immune response at antiretroviral treatment initiation and the following year in low- and middle-income countries where malnutrition is most prevalent. Our systematic review will identify studies originating from low- and middle-income countries (LMICs) published from 1996 onwards, through searches in MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and grey literature. No language restrictions will be applied. We will seek out studies of any design investigating the association between the nutritional status (for example, undernourished versus well nourished) and the immune response, either in terms of CD4 count or immune failure, in seropositive patients initiating antiretroviral therapy or in their first year of treatment. Two reviewers will independently screen articles, extract data and assess scientific quality using standardized forms and published quality assessment tools tailored for each study design. Where feasible, pooled measures of association will be obtained through meta-analyses. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. This protocol has been registered in the PROSPERO database (registration number: CRD42014005961). Undernutrition and weight loss are prevalent amongst highly active antiretroviral therapy (HAART)-treated patients in LMICs and contribute to excess early mortality. A possible intermediate pathway could be poor immune reconstitution secondary to deficient nutritional status. In the face of limited access to second line treatments, raising HIV resistance and cut backs to HIV programs, it is crucial to identify the factors associated with suboptimal response and therapeutic failure in order to better customize the care strategies employed in LMICs

Radiolabeled nano-peptides show specificity for an animal model of human PC3 prostate cancer cells

OBJECTIVES: Cancer has been investigated using various pre-targeting techniques or models focusing on radiobombesin analogues; however, both are not offered together. In this study, nano-bombesin labeling by a pre-targeting system was undertaken to develop an alternative approach for prostate tumor treatment. METHODS: A two-step pre-targeting system utilizing a combination of streptavidin (SA), biotinylated morpholino (B-MORF), biotinylated BBN (B-BBN) with two different spacers (b-Ala and PEG), and a radiolabeled cMORF was evaluated in vitro and in vivo. RESULTS: Final conjugation conditions consisted of a 1:1:2 ratio of SA:B-MORF:B-BBN, followed by addition of 99mTc-cMORF to compensate for free MORF. In vitro binding experiments with prostate cancer cells (PC-3) revealed that total binding was time-dependent for the Ala spacer but not for the PEG spacer. The highest accumulation (5.06 ± 1.98 %) was achieved with 1 hour of incubation, decreasing as time progressed. Specific binding fell to 1.05 ± 0.35 %. The pre-targeting biodistribution in healthy Swiss mice was measured at different time points, with the best responses observed for 7-h and 15-h incubations. The effector, 99mTc-MAG3-cMORF, was administered 2 h later. Strong kidney excretion was always documented. The greatest tumor uptake was 2.58 ± 0.59 %ID/g at 7 h for B-bAla-BBN, with a region of interest (ROI) value of 3.9 % during imaging. The tumor/blood ratio was low due to the slow blood clearance; however, the tumor/muscle ratio was 5.95. CONCLUSIONS: The pre-targeting approach with a peptide was a viable concept. Further evaluation with modified sequences of MORF, including less cytosine, and additional test intervals could be worthwhile